Summary The Beechcraft A100, registration C-FMAI, operated by Myrand Aviation Inc., was on a chartered instrument flight rules flight from Qubec/Jean Lesage International Airport, Quebec, to Chibougamau/Chapais Airport, Quebec, with two pilots and three passengers on board. The co-pilot was at the controls and was flying a non-precision approach for Runway05. The pilot-in-command took the controls less than one mile from the runway threshold and saw the runway when they were over the threshold. At approximately 1018 eastern daylight time, the wheels touched down approximately 1500feet from the end of Runway05. The pilot-in-command realized that the remaining landing distance was insufficient. He told the co-pilot to retract the flaps and applied full power, but did not reveal his intentions. The co-pilot cut power, selected reverse pitch and applied full braking. The aircraft continued rolling through the runway end, sank into the gravel and snow, and stopped abruptly about 500feet past the runway end. The aircraft was severely damaged. None of the occupants were injured. Ce rapport est galement disponible en franais. Other Factual Information The flight crew was certified and qualified for the flight in accordance with existing regulations. The pilot-in-command had 11 338flying hours, including about 11000hours of instrument flight. He was qualified on the BeechcraftA100 and had over 2600hours on type. He was pilot, chief pilot, company president and owner, and maintenance coordinator. As president, he controlled the company hiring and dismissal policies and was in charge of training pilots and applying flight procedures. The co-pilot had 1176flying hours, including about 500hours of instrument flight. He was qualified on the BeechcraftA100 and had about 400hours on type. The aircraft was certified, equipped and maintained in accordance with existing regulations and approved procedures. There was no evidence found of any airframe failure or system malfunction during the flight. When the aircraft rolled through the runway end, the landing gear was down and the flaps were retracted. The weight and centre of gravity were within the prescribed limits. The aircraft was equipped with a cockpit voice recorder (CVR), model Universal CVR30-B, serial number1135. This model is a semi-conductor recorder with four continuous-loop channels, which records all voice messages sent or received by the crew in the last 30minutes. The CVR was removed from the aircraft and sent to the TSB Engineering Laboratory for analysis. The information and conversations retrieved provided a record of the events that occurred during the last 30minutes of flight before the occurrence. At the time of the occurrence, Myrand Aviation Inc. was operating a fleet of three aircraft: a Cessna Citation, a Beechcraft A100 and a Cessna402. On 13April1999, a Cessna335 belonging to the company crashed on a missed approach at Gasp Airport, Quebec (TSB report No.A99Q0062). There were four fatalities. Prior to departing from Qubec, the pilot-in-command inquired about the weather at his destination. The terminal aerodrome forecast (TAF) for Chibougamau/Chapais Airport issued at 1137 Coordinated Universal Time (UTC), valid for the period 1200to 2400UTC, was as follows: winds 180degrees at 10knots, visibility over 6miles in light rain showers with ceiling 400feet and, temporarily from 1200to 2100UTC, ceiling 200feet broken and 2000feet overcast. While the aircraft was en route, a special weather observation made at 1316UTC, or 0916 eastern daylight time,1 was sent to the crew. It was as follows: winds 180degrees true at 9knots, visibility 4miles in light rain and fog, scattered cloud at 500feet and ceiling 1700feet. Between 0916 and the time of the accident, which occurred at 1018, there were two more special observations besides the aviation routine weather report (METAR) at 1400UTC for the Chibougamau/Chapais Airport. These last three observations indicated deteriorating weather conditions. However, they were not provided to the flight crew and were not requested by them. The last observation, which was made at 1400UTC, was as follows: winds 180degrees true at 6knots, visibility 2miles in light rain and mist, ceiling measured 400feet overcast. At approximately 0950, when the aircraft was about 60miles southeast of the Chibougamau/Chapais Airport, the descent was initiated. At the time, the aircraft was in uncontrolled airspace and radio communications were on the frequency 126.7MHz. About 50miles southeast of the airport, the flight crew estimated beacon CHIBOO in 18minutes for an approach for Runway23, which would be about 6minutes after the arrival of another aircraft, a Beechcraft 100inbound from the west. The pilots of the two aircraft established two-way communications to coordinate their intentions. C-FMAI advised that it would fly a holding pattern to let the other aircraft land. However, the altitude at which the holding pattern would be flown was not mentioned. Furthermore, the holding pattern was not flown as defined in the Instrument Procedures Manual (TP2076). The pattern was flown to the northeast of approach fix OMOLI on an outbound track; it should have been flown to the southwest of the approach fix on an inbound track. The Chibougamau/Chapais Airport is located in classG airspace and air traffic control (ATC) does not have the authority or responsibility to control the traffic there. ATC units do provide flight information and alert services. When aircraft operate near an uncontrolled airport or in classG airspace, pilots must broadcast their intentions on the mandatory frequency (MF). In this occurrence, the pilots of both aircraft used frequency 122.0MHz, the MFfor Chibougamau/Chapais, when closer to the airport. They broadcast their intentions and some position reports during the approach, including on final approach. Section 602.96(3)(b) of the Canadian Aviation Regulations (CARs) requires that the pilot-in-command of an aircraft operating at or in the vicinity of an aerodrome conform to or avoid the pattern of traffic formed by other aircraft in operation. However, the CARs are not explicit as to how aircraft are to avoid the pattern of traffic, either in terms of altitude or distance. Also, the CARs do not indicate whether the missed approach segment must be considered part of the pattern of traffic. Section 602.96(2)(a) of the CARs indicates that, before taking off from, landing or otherwise operating an aircraft at an aerodrome, the pilot-in-command of the aircraft shall be satisfied that there is no likelihood of collision with another aircraft or a vehicle. In accordance with the CARs, the pilot-in-command of C-FMAI decided to avoid the other aircraft by heading for OMOLI, the intermediate approach fix for Runway05, to fly a holding pattern and let the other aircraft land. The pilot-in-command also decided to fly the non-directional beacon/distance measuring equipment (NDB/DME) approach for Runway05 instead of an approach for Runway23. C-FMAI flew over OMOLI at an approximate altitude of 3000feet above sea level (asl), which could have contributed to a loss of separation or even a collision in the event that the other aircraft, which was approaching in the opposite direction, executed a missed approach that required it to climb to 3200feet on a heading of 237degrees, which is in the general direction of OMOLI, before heading for beacon MT. After the other aircraft reported on final, the flight crew of C-FMAI exited the holding pattern and advised that it was initiating the approach. The co-pilot was still at the controls. No instructions for an approach or missed approach were reviewed by the pilot-in-command with the co-pilot as indicated in the company standard operating procedures (SOPs) manual. When C-FMAI was established on final approach for Runway 05, the other aircraft advised that it was executing a missed approach. The crew of C-FMAI was surprised but still continued with the approach. Examination of the radar recordings revealed that the two aircraft crossed at 1015:27 in opposite directions with a distance of 2.1nm and vertical separation of 1000feet. Less than one mile from the runway threshold, the pilot-in-command took the controls. Visual contact with the runway was established when the aircraft was over the threshold of Runway05. The radar data indicate that, at that time, the aircraft was at an altitude of 1700feet asl, or 432feet above ground level (agl). He asked the co-pilot to fully extend the flaps and continued the descent. The pilot-in-command had been planning to execute a missed approach if the aircraft did not touch down abeam the taxiway located about 1800feet from the end of Runway 05. However, he did not tell the co-pilot what he intended to do. The aircraft touched down approximately 1500feet from the end of Runway05. A special observation was made at the same time, indicating winds 180 degrees true at 6knots, visibility 1miles in light rain and mist, ceiling measured 300feet overcast, visibility varying from 1to 2miles and ceiling from 200to 400feet. At the time of the accident, the runway was wet. The amount of water on the runway and the James Brake Index could not be determined. The minimum descent altitude (MDA) published for the NDB/DME approach for Runway05 is established at 1800feet asl, or 532 feet agl and visibility 1miles. Even though the ceiling was below the minimum published for an instrument approach during the approach, there were no regulations prohibiting the flight crew from executing the approach. With regard to landing, the existing regulations prohibit the pilot of an aircraft on an instrument approach from continuing the descent below the MDA if he or she has not established and maintained the visual reference required to carry out a safe landing. In that case, he must execute a missed approach. After the aircraft touched down, the pilot-in-command realized that the remaining runway distance was insufficient to bring the aircraft to a stop and asked the co-pilot to retract the flaps. The pilot-in-command applied full power for a take-off; however, he did not convey his intentions to the co-pilot. Seeing that the pilot-in-command did not have his hands on the power levers, the co-pilot thought that the pilot-in-command made an error by pushing forward the power levers instead of the propeller pitch controls. He immediately retarded the power levers, selected reverse pitch and applied maximum braking. The pilot-in-command was surprised at the actions of the co-pilot and let the aircraft lose speed, roll through the end of the runway and come to rest in the dirt and snow about 500feet past the runway end.